Session 15, February 12, 2019

Andrea Gelzer, M.D., M.S., FACP, Senior Vice President of Medical Affairs

Joe Miller, FHIMSS, Director of Strategy and Innovation

AmeriHealth Caritas Family of Companies

Five Best Practices for Improving Transitions

in Care with Health Information Exchange (HIE)

Andrea Gelzer, M.D., M.S., FACP

Has no real or apparent conflicts of interest to report.

Joe Miller, FHIMSS

Has no real or apparent conflicts of interest to report.

Conflict of Interest

• Session objectives.

• Overview of AmeriHealth Caritas Family of Companies.

• Value of HIEs.

• Our HIE experience.

• Five best practices.

• Wrap up.

• Questions.

Agenda

• Describe the current state of a health plan’s health information

exchange (HIE) engagement within the context of HIEs

nationally, and assess the opportunities for using data to

improve transitions of care in a multi-stakeholder and

resourced care community.

• Plan how to connect to HIEs for optimal value, identifying

essential processes and technologies that will help meet the

goal of improving transitions in care.

• Identify key limitations and challenges that can reduce the

value of HIE information, particularly when connecting to more

than one HIE, and how to address them to maximize return

on investment.

Session Objectives

• Has more than 35 years of experience

expanding access to care for members

and striving to maximize value for health

care providers, community organizations,

and government stakeholders.

• Is backed by two of the largest and

most well-respected Blue companies,

Independence Health Group and

Blue Cross Blue Shield of Michigan.

• Works every day to fine-tune the

future of health care through innovation,

compassion, and an unwavering

dedication to eliminating health disparities.

AmeriHealth Caritas

AmeriHealth Caritas Markets

Why Transitions in Care?

• It’s a vulnerable time for patients.

• Poorly managed transitions associated with increased rates of potentially

avoidable hospitalizations.

• Nearly 1 in 5 Medicare patients discharged from hospital are readmitted

within 30 days.

• Fewer than 50% of patients see their primary care provider (PCP) within

14 days of hospital discharge.

Sources: Kashiwagi, et al, “Do Timely Outpatient Follow-up Visits Decrease Hospital Readmission Rates?”, American Journal of Medical Quality,

August 2011. “Community-based Care Transitions Program”, https://innovation.cms.gov/initiatives/cctp, accessed January 8, 2019.

• Care transitions offer a good opportunity to intervene.

• Successful handling reduces cost.

• Failure rates are easily measurable.

• Encounter notification data are readily available.

• Best practices are applicable to future use cases.

It’s a Place to Prove Value

Our HIE Journey and

State HIE Connection History

Invested in HIE

infrastructure

and founded

HealthShare

Exchange

(HSX) in

Pennsylvania

Implemented

multi-state

HIE gateway

Integrated

transactions

coming through

our HIE gateway

with back-end

systems

Fully

integrated

to care

management

and provider

applications

Pilot with

Chesapeake

Regional

Information

System for Our

Patients

(CRISP) to

determine value

of leveraging

HIE

District of

Columbia

Southeastern

Pennsylvania

Louisiana

Michigan

Florida Delaware

2014 2015 2016 2017 2018 2019

State HIE connections

Central

Pennsylvania

Implement

FHIR API

pilot

Expand direct

secure

messaging

capabilities

HIE at a Glance

State/regional HIEs exchanging

data with our health plans

1,641

Hospitals sending data

to our plans via HIE

1.3M

Members in plans exchanging

information with HIEs

275,009

Continuity of Care Documents

(CCDs) received through HIEs

3.8M

Admission, discharge, and transfer

(ADT) encounter notification alerts

Collaboration With State HIEs

Plan

HIE

Transactions

(August 2017 –

August 2018)

AmeriHealth Caritas Louisiana

Louisiana Health Information

Exchange (

LaHIE)

100,379

Keystone First and

Keystone First VIP Choice

HealthShare

Exchange (HSX)

778,996

Prestige Health Choice

Florida HIE Services

(FL HIE)

374,035

AmeriHealth Caritas District

of Columbia

Chesapeake

Regional Information

System for Our Patients (

CRISP)

181,139

AmeriHealth Caritas VIP Choice and

Blue Cross Complete of Michigan

Michigan

Health Information

Network (

MiHIN) Shared Services

981,024

AmeriHealth Caritas Delaware

Delaware

Health Information

Network (D

HIN)

5,400*

* Implemented 2018

AmeriHealth Caritas HIE Model

1. Participating facilities send ADT alerts and CCDs to AmeriHealth

Caritas via the HIE in real time or near real time (within 24 hours).

2. Our HIE gateway validates the member and applies rules and

predictive modeling.

3. Alert information is routed into the workflow of AmeriHealth Caritas

care managers and providers.

Five Best Practices

Obtaining and using HIE data

in near real time

Real-time data

Using clinical markers to hone

in on critical cases

Predictive analytics

Integrating the information

with back-end processes

Back-end integration

Enriching the data to see the

whole person needs

Enrich data

Closing the loop through

bi-directional exchange

Bi-directional exchange

Best Practice 1:

Build for Real-Time Data

• Provides access to the right information, for the right person,

at the right time.

• Enables timely patient follow-up.

• Enables physicians to make better decisions.

HIEs with real-time APIs

• HealthShare Exchange (ADTs and CCDs).

• Michigan Health Information Network (ADTs and CCDs).

• Delaware Health Information Network (ADTs).

Getting To Real Time Data

Hospital

discharge

HIE receives HIE sends Lapsed time

Best case

Monday

5:46 a.m.

Monday

5:47 a.m.

Monday

6:00 a.m.

14 minutes

Average

Thursday

3:59 a.m.

Thursday

4:15 a.m.

Thursday

6:17 a.m.

2 hours,

18 minutes

Worse case

Tuesday

6:59 a.m.

Wednesday

4:45 a.m.

Thursday

5:00 a.m.

45 hours,

59 minutes

The Trends We’re Seeing

• 74 percent of inpatient discharge transactions and 62 percent of

emergency discharge transactions were transmitted from the point of

service to the HIE and then to AmeriHealth Caritas within four hours.

• A few outliers were observed where there was a latency in the timing

of the facility sending data to the HIE.

* Dataset uses a representative sample for one HIE for a two-week period in October to November 2018.

0 500 1000 1500 2000 2500 3000 3500 4000 4500

< 4 hrs

4 -12 hrs

12- 24hrs

> 24hrs

< 4 hrs 4 -12 hrs 12- 24hrs > 24hrs

Inpatient

1365 59 510

Emergency

4040 658 439 2445

Real-time ADT data

• Build for APIs for data exchange.

• Remove latency at all steps.

• Set expectations for real time with HIEs and facilities.

• Monitor continuously to identify problems.

• Create a flexible HIE “gateway” that can connect to multiple partners.

• Challenges: Some facilities and HIEs do not provide real-time exchange,

but rather a daily batch exchange.

Best Practice 1 Guidance

• Volume of transactions is enormous.

• Not all discharges are created equal.

• Data within the ADT transaction is limited, and facilities vary in how much

information they send. (See below sample from an actual report.)

Best Practice 2:

Apply Predictive Analytics Filters

Hospital

Admit reason Diagnosis

GENERAL WEAKNESS, chest pain

(No diagnosis provided)

fever, fever unspecified R50.9 FEVER, UNSPECIFIED

2 (No admit reason provided) (No diagnosis provided)

Information from three unique ADT messages for ER visits

Finding the Needle in the Haystack

Integrated into care

management workflow

Meeting high-risk criteriaHIE ADT alerts

* Aggregated data are representative for July 2018.

• Analytic risk stratification predictive models that use various parameters

(e.g., demographics or gaps in care) are applied to member data for

targeting members in need of care.

• Targeted members’ ADT data is then integrated into the back-end

processes for effective care coordination.

• Work with clinical staff to select key clinical markers that can be used

to stratify the alerts to identify the most important ones.

• Obtain data and integrate into the HIE alert receipt process.

• Refine markers as appropriate.

• Challenge: Clinical markers for providers may be different than for

care managers.

Best Practice 2 Guidance

• Care managers are the primary users of HIE information

within the payer organization.

• Initially, distributing HIE data on reports is adequate.

• Eventually, busy care managers will require HIE information

in their workflow.

Best Practice 3:

Integrate with Workflow

Integration with

Back-End Processes

Care

management

ADT data is integrated

into care management

application based on

pre-defined workflow

rules. This allows care

managers to:

• Create event

records and

authorizations.

• Update discharge

information.

• Close inpatient

cases.

Clinical data

repository

• Store ADT

information in

clinical repository.

• Integrate ADT

information with

member’s clinical

history data for

enriched reporting.

HEDIS

• Key CCD data is

parsed and used

to support HEDIS

measures where

appropriate.

• Vital signs are

particularly valuable.

Provider portal

• ADT data is

integrated into

provider portal

applications based

on pre-defined

rules.

• Tight integration with care management system using standard

worklists and other triggers is optimal.

• HIE data should also be integrated into the broader analytics

environment of the organization.

• Build in method to measure care manager follow-up and

feedback loop to management.

• Challenge: Finding the balance of volume versus the value for

alerts to care managers and providers.

Best Practice 3 Guidance

• Data in ADT transaction is very limited (see below).

• CCD, when received, provides a limited snapshot of the

member’s condition.

• Presenting information from other sources is needed for an

adequate understanding to facilitate the transition in care for

the care manager and provider.

Best Practice 4: Enrich Data

for Whole-Person Needs

Hospital

Admit reason Diagnosis

GENERAL WEAKNESS, chest pain

(No diagnosis provided)

fever, fever unspecified R50.9 FEVER, UNSPECIFIED

(No admit reason provided) (No diagnosis provided)

Information from three unique ADT messages for ER visits

• Member data enriched by

aggregating and combining

data from different sources.

• Provides a comprehensive

360° view of the member’s

information.

• Fulfills whole-person

needs.

Clinical

conditions

Social

determinants

Observations

Tests and

services

Office visits

ImagingLab

Data Enrichment for

Whole-Person Needs

Clinical Summary Provides

Full View

* Sample member data

• Offer the care team a summary of the member’s clinical

history that can be easily used to support the transition.

• Ensure data crosses all care sites, including the most recent

facility encounter.

• Provide behavioral health and social determinants

information, which can heavily factor into the transition.

• Challenge: Integrating all data sources.

Best Practice 4 Guidance

Best Practice 5:

Multi-Directional Data Exchange

• HIEs tend to be uni-directional.

• Provider practices and post-acute care providers are often

the last to become connected, but they are the most

important recipients of information.

• Health plans need to encourage partners to connect to

existing channels and, where these are inadequate,

provide information through their own channels.

Typical and Ideal

Information Exchange

Facility HIE Plan

Primary

care

Post-

acute

Specialist

Current experience

Strong Somewhat Weak

HIE

Payer Portal Provider

HIE

Payer

Electronic

health

record

Provider

Optimal

Plan Options for Sharing

Relevant Information

• Identify the gaps in HIE coverage, with key organizations

involved in the care team.

• Advocate for improvement in HIE coverage to fill gaps.

• Look at existing or new plan capabilities to share data such

as portals, direct, and Fast Healthcare Interoperability

Resources (FHIR).

• Challenge: Integrating data into the care team provider’s

electronic health record.

Best Practice 5 Guidance

Benefits and Challenges

Deliver the right information, on the right patient, to the

right provider, at the right time.

Best practice

Right

information

Right

patient

Right care

manager

provider

Right time

Real-time delivery

Analytics filters

Integrated with

the back end

Comprehensive

information

Multi-directional

Benefits of HIE: Aligned to Triple-Aim Goals

Improved health outcomes

• Effective coordination of care between providers.

• Integration of physical and behavioral health care

into a care plan.

Better care

• 360° view of member health.

• Reduction in missed or delayed diagnoses.

• Reduction in adverse events.

• Improved health monitoring and reporting.

Reduced utilization costs

• Reduction in readmissions.

• Reduction in the frequency of ER visits.

• Prevention of duplicative or repeat tests

(e.g., lab work and diagnostics).

• Reduction in the length of hospital stays.

Questions?

Andrea Gelzer, M.D., M.S., FACP

agelzer@amerihealthcaritas.com

Joe Miller, FHIMSS

jmiller@amerihealthcaritas.com